Anterior clinoidal meningioma coincidental with bilateral intracranial aneurysms.

Coexistence of aneurysms and brain tumors is a rare occurrence. Coincidence is highest in patients with meningiomas rather than other types of tumors. We report a case in which a meningioma of the left anterior clinoid process was coexisting with a right middle cerebral artery (MCA) and a left anterior cerebral artery (ACA) aneurysm. While the right MCA aneurysm was detected preoperatively, the left ACA aneurysm was not detectable, being concealed by the major finding of the region. This report focuses on pitfalls of diagnosis and questions the surgical planning in aneurysms concealed by coincidental brain tumors.

Frequent abnormalities of the immune system in gliomas and correlation with the WHO grading system of malignancy.

AIM: To investigate the cellular and humoral immunity status of gliomas, and their association with the WHO grading system. MATERIAL AND METHODS: We have conducted a case-control study of 49 patients with gliomas and 30 healthy controls. We used ELISA assays, radial immunodiffusion, indirect immunofluorescence, latex test and flow cytometry assays to estimate preoperative in serum the immunological profile. RESULTS: Patients with glioma had significantly reduced amounts of IL2 (p=0.000), TNF-a (p=0.033), IgG (p=0.011), IgA (p=0.027),C4 (p=0.026) ,CD3+ (p=0.001), CD4+ (p=0.000), CD8+ (p=0.002), ratio CD4/CD8 (p=0.000), CD19+ (p=0.04) and elevated IL10 (p=0.05) compared with healthy controls. No statistically significant differences were observed concerning viral agents, total NK cells, IgM, IgE, IL16, granzyme-b, RF, ANA, ENA, anti-dsDNA and anti-cardiolipin antibodies. A higher WHO grade, after controlling for age and gender, was associated with decreased number of CD3+ (p=0.011), CD4+ (p=0.015), CD8+ (p=0.048) and ratio CD4/CD8 (p=0.027), as well as with decreased IL2 (p=0.018), C4 (p=0.02), and IgG (p=0.05). IL2 and CD4+ counts were significant predictors of grade. CONCLUSIONS: A shift from Th1 to Th2, a CD3+ and CD19+ lymphocytopenia, a diminished fraction CD4/CD8 and a reduced amount of immunoglobulins and complement were observed in the patients with gliomas. A higher WHO grade of the tumor was associated with greater impairments of immunity. Since defects of both humoral and cellular immunity were equally observed and significant predictors of grade were assessed, a preoperative evaluation of the immune system of patients with gliomas is being proposed.

Magnetic stimulation of the spine: the role of tissues and their modelling.

Numerical modelling of magnetic stimulation in the spine is a scarce subject in the literature, although it has been gaining clinical acceptance. In the present work we present the results from a simplified computational model of the spine. The results indicate that it is necessary to use a numerical technique for solving the problem, which takes into account tissue dispersion and both dielectric properties (conductivity and permittivity), since a difference of 14% in the induced electric fields was found when displacement currents were included. With respect to the role of tissues in stimulation efficiency, it was confirmed that water-rich tissues lead to a shielding effect of the spinal cord. However, this effect becomes smaller at the height of the intervertebral discs, resulting in an increase of the field inside the spine.

Primary extracerebral meningeal glioblastoma: clinical and pathological analysis.

Primary meningeal gliomas are uncommon tumors in the subarachnoid space, their primary characteristic being the absence of any obvious connection to the brain parenchyma. Rarely, they are quite malignant and assume a bulky, well circumscribed appearance rendering the differential diagnosis from other CNS neoplasms difficult. A 53-year-old man presented with a history of persistent headaches and left sided weakness. Magnetic resonance imaging revealed a temporoparietal mass attached to the dura that strongly resembled a meningioma. At surgery, the outer layer of the dura mater was intact and there was a clear brain-tumor interface without obvious pial disruption. Histological examination showed a biphasic pattern consisting of benign connective tissue intermingled with bundles of what seemed to be a glioblastoma. The mass demonstrated strong positivity for GFAP and the MIB labeling index focally exceeded 20%. The tumor was identified as a primary meningeal glioblastoma. The patient was disease-free for 42 months, after which he developed a recurrence for which he was re-operated. This time, the pathological findings of the tumor were those of a typical glioblastoma multiforme. We discuss the origin of the initial neoplasm and also the differential diagnosis that needs to include meningioma, aggressive glioblastoma infiltrating the dura and a recently recognized bimorphic CNS tumor: the desmoplastic glioblastoma.

Descriptive epidemiology of cerebral gliomas in northwest Greece and study of potential predisposing factors, 2005-2007.

BACKGROUND: To investigate the epidemiologic and clinical characteristics (age, sex, tumor location, socioeconomic status) and potential predisposing factors (alcohol, tobacco, mobile phone use, severe head trauma) of cerebral gliomas in a defined area of Northwest Greece. METHODS: The prospective study was conducted in patients with gliomas referred to all 7 hospitals of a study area with a population of 488,435 inhabitants, from June 1, 2005, to May 31, 2007. Incidence rates (IR) were calculated as new cases diagnosed among residents of the study area during the study period per 100,000 inhabitants. A case-control study was carried out in order to study the possible association of the risk of glioma with smoking, alcohol, use of mobile phone, and severe cranial trauma. RESULTS: A total of 56 glioma incident cases were identified with IRs of glioma and glioblastoma (GBM) at 5.73/10(5)/year and 3.69/10(5)/year, respectively. A male to female ratio of 1.25 was obtained in the GBM group. IRs of glioma and GBM for both males and females were higher in the age group 60-79. The most frequent anatomic location was the frontal lobe. 46.5% of the patients originated from the low, 25% from the middle and 28.5% from the high socioeconomic class. There was no significant association between glioma and alcohol consumption, smoking and mobile phone use. A trend for a positive association between the risk of glioma and a history of severe cranial trauma was observed, but this association was not statistically significant. CONCLUSION: The estimated IR of glioma and GBM in this study was higher compared with data from other studies carried out on European, Asian and US populations. Further studies may be needed to assess the possible association of genetic, environmental and lifestyle factors with the high occurrence of gliomas observed in this study.

Multifocal glioblastoma with remote cutaneous metastasis: a case report and review of the literature.

BACKGROUND: Remote extracranial mestastases of glioblastoma multiforme (GBM) are uncommon, while cutaneous seeding at a distance from the operative site appears to be even more unusual. CASE REPORT: A 63-year-old man presented with focal seizures and mental impairment. Computed tomography (CT) scan revealed a left frontoparietal mass. He underwent a gross total removal of the tumor. The tissue diagnosis was that of a GBM. Seven months later, the patient developed a left scapular subcutaneous mass. Fine-needle aspiration cytology (FNAC) was performed and the cytological findings disclosed again a GBM. One month later, after clinical deterioration, a repeat magnetic resonance imaging (MRI) scan was carried out which demonstrated two new distinct lesions in the opposite hemisphere, as in a multifocal GBM. Both lesions were biopsed under stereotactic guidance and the recurrence of GBM was confirmed. The patient died ten months after the primary diagnosis of the intracranial GBM. CONCLUSION: Improved diagnostic modalities and prolonged survival have increased the likelihood of detection of extracranial mestastases from GBM. This potential may be greater in multifocal GBM. FNA is a valuable method for the definite diagnosis of metastatic GBMs. Although several theories have been postulated, the route of remote cutaneous dissemination and the mechanism of multifocal recurrence remain to be elucidated.

Solitary plasmacytoma of the upper cervical spine: therapeutic considerations.

Solitary plasmacytomas are localized plasma cell malignancies involving bone marrow (solitary bone plasmacytoma, SBP) or extramedullary tissues (solitary extramedullary plasmacytoma, SEP). The upper cervical spine involvement by SBP is a rare and more challenging condition. The authors describe a patient with solitary plasmacytoma involving all the elements of C2 vertebra. Severe neck pain was the only manifestation of disease. The patient underwent an occipito-cervical stabilization with a partial decompression through a single posterior approach. The authors stress the importance of early diagnosis followed by appropriate multidisciplinary treatment strategies, including surgery and discuss the management dilemmas concerning the timing and management consequence, in scope to prevent a major neurological damage and allow the patient to be ambulatory.

Subependymal giant cell astrocytoma with intratumoral hemorrhage in the absence of tuberous sclerosis.

Subependymal giant cell astrocytoma (SEGA) is an uncommon tumor that usually occurs in the setting of tuberous sclerosis (TS) syndrome. We report a rare case of an intratumoral and a small intraventricular hemorrhage complicating a SEGA in an adult patient without any signs of TS. Although pre-operative CT and MRI findings for the tumor were typical of SEGA, SEGA was not considered in the differential diagnosis because the patient was lacking any symptoms of TS. This is the second report of intraventricular and intratumoral hemorrhage complicating a SEGA and the first case in which these complications occurred in an adult patient in whom there was no previous suspicion of systemic disease.

Suprasellar and intrasellar paragangliomas.

Neoplasms of the sellar region are entities with a large differential diagnosis. Although paraganglionic cells have not been demonstrated in the pituitary or adjacent structures, the existence of sellar region paragangliomas is well-documented. To elucidate, in this area the nature of these unusual tumors is relatively difficult. Clinical history, physical examination, radiographic investigation as well as intraoperative gross observation are the same as those of sellar meningioma or pituitary adenoma. Immunohistochemistry, using neuroendocrine markers and electron microscopy are the two definitive diagnostic methods to differentiate among these entities. The clinical management, the possible pathogenesis of the tumor, the importance of immunohistochemistry in making the diagnosis and the clinical outcome of these patients are discussed.

A sphenoid en plaque meningioma aggravates exophthalmos in a patient with thyroid ophthalmopathy.

PURPOSE: To describe the rare case of a patient with thyroid ophthalmopathy whose unilateral aggravated exophthalmos was caused by the development of an ipsilateral sphenoid wing en plaque meningioma. METHODS: Case report. RESULTS: The ophthalmologic examination included visual acuity assessment, anterior segment examination, funduscopy, ocular motility examination, and exophthalmometry. Magnetic resonance imaging (MRI) of the brain and orbit revealed the existence of a sphenoid meningioma. Removal of the tumor through a pterional craniotomy was performed. The histologic examination showed that it was an en plaque meningioma. There were no postoperative complications and no recurrence of the tumor was revealed 24 months after the operation. CONCLUSIONS: Detailed ophthalmologic examination and MRI of the brain and orbit are necessary in every patient with deterioration of the exophthalmos even if the suggestive cause seems obvious.

p53 enhances the Delta-24 conditionally replicative adenovirus anti-glioma effect.

Previous studies have demonstrated that the conditionally replicative adenovirus Ad5Delta24 is a powerful cytolytic agent against glioma selectively affecting cells with a defective p16/Rb/E2F pathway. The p53 protein is also known to be an apoptotic factor for glioma cells. In this study, we examined the simultaneous delivery of the combination of exogenous p53 and Ad5Delta24 adenovirus in glioma cells. Infecting cells with low doses of adenovirus p53 and Ad5Delta24 resulted in an additive effect on cell death. The cell death induced by both agents was independent of the p53 status of cells. Flow cytometry revealed that the potent anti-tumor effect induced by the mixture of Ad5CMV-p53 and Ad5Delta24 adenoviruses was due to a combination of apoptosis and cell lysis. Our results indicate that Ad5CMV-p53 enhances the oncolytic effect of the Ad5Delta24 adenovirus, and the combination of adenovirus Ad5Delta24 and Ad5CMV-p53 may thus be a potential therapeutic tool for gliomas.

Imaging findings in paraspinal extra osseous Ewing sarcoma.

We present a case of extraskeletal Ewing sarcoma (ES) in a 32-year-old male patient. The patient reported a painful mass in the thoracic paraspinal area which reached a considerable size in a one-month interval. Sonography and CT showed a heterogeneous, hypoechoic/hypodense soft tissue mass embedded in the dorsal paraspinal musculature. MRI with contrast enhancement showed a solid tumor surrounding areas of necrosis/cystic degeneration. Despite wide contact with the spine and ribs there was no intrathoracic/intraspinal extension or neural foraminal invasion. The imaging findings are non specific; a paravertebral location in the appropriate age group may be the clue to the diagnosis of extraskeletal ES.

Subdural empyema and cerebellar abscess due to chronic otitis media.

The infratentorial variety of the subdural empyema, with or without coexisting cerebellar abscess, is a rare clinical entity that carries a high mortality rate. We briefly describe the case of a 49-year-old man presented with severe debility, fever and an obviously neglected chronic otitis media. The patient had refused surgical treatment several months ago. After admission, his level of consciousness began to deteriorate, and the radiological studies showed infratentorial subdural suppuration extending into the right cerebellar hemisphere, along with chronic pyogenic infection of the middle ear and the mastoid process. Radical mastoidectomy was performed first, followed by extensive right posterior fossa craniectomy. The two subdural collections and the cerebellar abscess were successfully evacuated. Subsequently, he received post-operative antibiotic treatment for 6 weeks. At follow-up, 10 months after surgery, his neurological recovery was complete except for a minor residual cerebellar dysfunction on the right. This unusual case highlights that in patients presented with severe intracranial complications of chronic otitis media, early diagnosis and radical surgical intervention may be life saving.

Transsphenoidal extradural chiasmapexy in the management of the symptomatic primary empty sella syndrome.

When patients with the usually clinically silent primary empty sella syndrome become symptomatic through visual field defects or hormonal deficits the condition was frequently treated by a transsphenoidal intradural procedure with a risk of consecutive CSF leak or meningitis. We present 3 cases in which we performed a transsphenoidal extradural procedure packing the sella and sphenoid sinus with fat tissue and discuss the procedure and results.